An assessment collects information that helps the health care team identify and manage problems a patient may have in adjusting to a change in care.

Having cancer affects more than the patient's physical condition. It also affects mental health, family life, ability to work, financial planning, social relationships, and faith. Many patients will encounter problems in one or more of these areas as they transfer from one level of care to another. For example, a patient’s family may have problems obtaining special home equipment or learning to use special equipment. Another patient may have a difficult time accepting the change from anticancer care to symptom relief alone, such as that provided with some types of palliative or hospice care. Transitional care planning is unique to each patient and family. Assessments help identify patients who may have problems during the transition and help determine the kind of support they will need to make the change go smoothly. The assessments may include a complete medical history; a physical exam; a test of learning skills; tests to determine ability to perform activities of daily living; a mental health evaluation; a review of social support available to the patient; and referral to community resources as needed to assist with issues such as transportation, home care, healthy eating, and medication management.

Assessments are done many times during the patient's cancer experience, as a routine part of care.

Assessments are done when the patient moves from one facility to another, such as from hospital to home. They are also done at regular times during the course of the disease, usually at the time of diagnosis, after completing a course of treatment, when there is a relapse, when curative treatment stops, and when treatment is discontinued (end-of-life care begins). The patient may feel added emotional stress at these times. Regular assessments can identify these and other causes of distress in the patient, such as job loss or the death or illness of a patient's loved one or caretaker. (Refer to the PDQ summary on Loss, Grief, and Bereavement ¹ for more information.)

Because no one knows what the patient’s needs will be in the future, assessments are done many times during the cancer experience as a routine part of care. This is helps ensure the patient receives the right services at the right times.

All members of the patient’s health care team are involved in the assessment process.

In planning for a change in cancer care, doctors, nurses, and other members of the patient’s health care team will consider all the areas of a patient’s life that may be affected. The following professionals may each conduct different parts of the transitional care planning assessment:

• Doctor.
• Nurse.
• Dietitian.
• Social worker.
• Psychologist.
• Chaplain.
• Physical therapist.
• Occupational therapist.

The following types of assessments will be done for transitional care planning:

Physical assessment

A physical assessment will look at the patient's general health, treatment plan, and changes in disease status, including the following factors:

• Type and stage of the cancer.
• Symptoms of the cancer.
• Side effects of treatment.
• Whether the patient smokes.
• Nutrition -related side effects and complications.
• Ability to perform activities of daily living.

Refer to the following PDQ summaries for more information:

• Nutrition in Cancer Care ²
• Smoking Cessation and Continued Risk in Cancer Patients ³

Family and home assessment

Factors such as the patient's age and living arrangements may affect how easily a change in level of care can be accomplished. The assessment will look at the following:

• Age of the patient and family members.
• Living arrangements.
• Whether the patient has a spouse or children.
• Level of education of the patient and family.
• Language spoken in the home.
• Cultural beliefs and practices.
• Whether family and friends are able to help during treatment.
• The age and floor plan of the home. Will medical equipment (such as a hospital bed, oxygen tank, or portable monitor) fit in the bedroom, if needed, and is wiring adequate? Can a person in a wheelchair move through the house easily?

Mental health assessment

Change can be a stressful time for both the patient and family. The nature of the relationship between the patient and his or her family and others helps determine the kinds of services the family may need to cope with the transition. The following questions may be asked:

• How do the patient and family feel about the cancer, the treatment, and the treatment goals? Sometimes patients develop serious problems such as depression or anxiety. Family members also may need help dealing with their feelings. These problems are often treatable. The doctor or health care professional can make referrals to a support group, counselor, or mental health care worker.
• What beliefs and values are important to the patient and do they affect the patient’s treatment decisions?
• How has the family coped with stress and crisis in the past? This may be helpful in predicting how they will react to the stress caused by the changes in the patient's treatment.
• Are there problems in the home that are unrelated to the cancer but may affect how well the patient and family can handle the change?
• Are there current or past mental health problems in the family?
• Has there been physical or sexual abuse in the patient's past?
• In the case of a patient considering home care, does the patient or any family member smoke or use drugs or alcohol? Smoking is not safe around oxygen equipment. Family members responsible for giving the patient medicines or other care must be clear-headed and not under the influence of any substance that could affect their ability to provide care in the prescribed way.

Refer to the following PDQ summaries for more information:

• Anxiety Disorder ⁴
• Depression ⁵
• Normal Adjustment and the Adjustment Disorders ⁶
• Post-traumatic Stress Disorder ⁷
• Substance Abuse Issues in Cancer ⁸

Social assessment

Doctors and other health care professionals can provide referrals to supportive services available to the patient. A review of the kinds of social services already available to the patient will be done:

• What kind of support is available in the home and community? How will the patient travel to medical appointments or other places? Who can the patient call on for help if necessary? Where the patient lives may affect what services are available and how the patient can get to appointments. Referrals can be made to local providers of services such as home nursing, food and medication delivery, and transportation to and from treatment centers.
• Does the patient understand hospice care and palliative care and know about available programs in the community?
• Before home care is considered, the availability of in-home help must be determined. Is there someone at home who can help the patient or will outside help be needed?
• Will the primary caregiver have anyone to help with the caregiving duties and make it possible to take time off?
• How will the change affect the patient’s ability to work?
• Does the patient have insurance coverage (group coverage from a job, Medicare, Medicaid, veteran’s benefits, or other)?
• What are the patient’s financial resources? How will the cost of care be paid?

Spiritual assessment

Knowing the role that religion and spirituality play in the patient's life help the health care team understand how these beliefs may affect the patient's transition to a new level of care. A spiritual assessment may include the following questions:

• Does the patient consider himself or herself to be a spiritual person?



• What is the importance of religion to the patient?



• Is the cancer or its treatment causing spiritual distress?



• Is support available from the patient’s religious group? Many patients find visits from members of their religious group valuable. A patient may want to talk to a spiritual advisor (for example, a priest, rabbi, or minister) during treatment.

Most hospitals, especially larger ones, employ hospital chaplains who are trained to work with medical patients and their families. Hospital chaplains are trained to be sensitive to a range of religious and spiritual beliefs and concerns.

(Refer to the PDQ summary on Spirituality in Cancer Care ⁹ for more information.)

Legal assessment

Advance directives and other legal documents can help doctors and family members make decisions about treatment should the patient become unable to communicate his or her wishes. The patient may be asked if he or she has prepared any of the following documents:

• Advance directive: A general term for different types of documents that state what an individual's wishes are concerning certain medical treatments when the patient can no longer communicate those wishes. The patient may declare the wish to be given all possible treatments that are medically appropriate, only some treatments, or no treatment at all.
• Health care proxy (HCP): A document in which the patient identifies a person (called a proxy) to make medical decisions if the patient becomes unable to do so. The form may not need to be notarized, but it must be witnessed by two other people. The patient does not have to state specific decisions about individual treatments, only that the proxy may make medical decisions for him or her. HCP is also known as durable power of attorney for health care (DPOAHC) or medical power of attorney (MPOA).
• Living will: A living will is a legal document in which a person states that they want certain life-saving medical treatments to be either withheld or withdrawn under certain circumstances. A living will is a type of advance directive. Living wills are not legal in all states.
• Durable power of attorney: A document in which the patient names another person to make legal decisions for him or her.
• Do Not Resuscitate (DNR) order: A document in which the patient instructs doctors not to perform cardiopulmonary resuscitation (restart the heart) at the moment of death, so that the natural process of dying occurs. A DNR order may be medically appropriate when cardiopulmonary resuscitation is not likely to save the patient's life.

Glossary Terms

ADL. The tasks of everyday life. These activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet. Instrumental activities of daily living are activities related to independent living and include preparing meals, managing money, shopping, doing housework, and using a telephone. Also called ADL.

A legal document that states the treatment or care a person wishes to receive or not receive if he or she becomes unable to make medical decisions (for example, due to being unconscious or in a coma). Some types of advance directives are living wills and do-not-resuscitate (DNR) orders.

Feelings of fear, dread, and uneasiness that may occur as a reaction to stress. A person with anxiety may sweat, feel restless and tense, and have a rapid heart beat. Extreme anxiety that happens often over time may be a sign of an anxiety disorder.

In healthcare, a process used to learn about a patient’s condition. This may include a complete medical history, medical tests, a physical exam, a test of learning skills, tests to find out if the patient is able to carry out the tasks of daily living, a mental health evaluation, and a review of social support and community resources available to the patient.

A term for diseases in which abnormal cells divide without control. Cancer cells can invade nearby tissues and can spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord.

Having to do with the heart and lungs.

A member of the clergy in charge of a chapel or who works with the military or with an institution, such as a hospital.

To heal or restore health; a treatment to restore health.

A mental condition marked by ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life. Other symptoms of depression include feelings of worthlessness and hopelessness, loss of pleasure in activities, changes in eating or sleeping habits, and thoughts of death or suicide. Depression can affect anyone, and can be successfully treated. Depression affects 15-25% of cancer patients.

The process of identifying a disease by the signs and symptoms.

A health professional with special training in nutrition who can help with dietary choices. Also called a nutritionist.

Do not resuscitate order. A type of advance directive in which a person states that healthcare providers should not perform cardiopulmonary resuscitation (restarting the heart) if his or her heart or breathing stops. Also called do not resuscitate order.

Any substance, other than food, that is used to prevent, diagnose, treat or relieve symptoms of a disease or abnormal condition. Also refers to a substance that alters mood or body function, or that can be habit-forming or addictive, especially a narcotic.

DPA. A type of power of attorney. A power of attorney is a legal document that gives one person (such as a relative, lawyer, or friend) the authority to make legal, medical, or financial decisions for another person. It may go into effect right away, or when that person is no longer able to make decisions for himself or herself. A durable power of attorney remains in effect until the person who grants it dies or cancels it. It does not need to be renewed over time. Also called DPA.

Healthcare proxy. A type of advance directive that gives a person (such as a relative, lawyer, or friend) the authority to make healthcare decisions for another person. It becomes active when that person loses the ability to make decisions for himself or herself. Also called healthcare proxy.

A program that provides special care for people who are near the end of life and for their families, either at home, in freestanding facilities, or within hospitals.

A type of legal advance directive in which a person describes specific treatment guidelines that are to be followed by health care providers if he or she becomes terminally ill and cannot communicate. A living will usually has instructions about whether to use aggressive medical treatment to keep a person alive (such as CPR, artificial nutrition, use of a respirator).

A person’s overall psychological and emotional condition. Good mental health is a state of well-being in which a person is able to cope with everyday events, think clearly, be responsible, meet challenges, and have good relationships with others.

A specialist who can talk with patients and their families about emotional and personal matters, and can help them make decisions.

A health professional trained to care for people who are ill or disabled.

The taking in and use of food and other nourishing material by the body. Nutrition is a 3-part process. First, food or drink is consumed. Second, the body breaks down the food or drink into nutrients. Third, the nutrients travel through the bloodstream to different parts of the body where they are used as "fuel" and for many other purposes. To give the body proper nutrition, a person has to eat and drink enough of the foods that contain key nutrients.

A health professional trained to help people who are ill or disabled learn to manage their daily activities.

Treatment given to relieve the symptoms and reduce the suffering caused by cancer and other life-threatening diseases. Palliative cancer therapies are given together with other cancer treatments, from the time of diagnosis, through treatment, survivorship, recurrent or advanced disease, and at the end of life.

PDQ is an online database developed and maintained by the National Cancer Institute. Designed to make the most current, credible, and accurate cancer information available to health professionals and the public, PDQ contains peer-reviewed summaries on cancer treatment, screening, prevention, genetics, complementary and alternative medicine, and supportive care; a registry of cancer clinical trials from around the world; and directories of physicians, professionals who provide genetics services, and organizations that provide cancer care. Most of this information, and more specific information about PDQ, can be found on the NCI's Web site at http://www.cancer.gov/cancertopics/pdq. Also called Physician Data Query.

An exam of the body to check for general signs of disease.

A health professional who teaches exercises and physical activities that help condition muscles and restore strength and movement.

A specialist who can talk with patients and their families about emotional and personal matters, and can help them make decisions.

The return of signs and symptoms of cancer after a period of improvement.

A problem that occurs when treatment affects healthy tissues or organs. Some common side effects of cancer treatment are fatigue, pain, nausea, vomiting, decreased blood cell counts, hair loss, and mouth sores.

A community resource that helps people in need. Services may include help getting to and from medical appointments, home delivery of medication and meals, in-home nursing care, help paying medical costs not covered by insurance, loaning medical equipment, and housekeeping help.

A network of family, friends, neighbors, and community members that is available in times of need to give psychological, physical, and financial help.

A professional trained to talk with people and their families about emotional or physical needs, and to find them support services.

Having to do with deep, often religious, feelings and beliefs, including a person’s sense of peace, purpose, connection to others, and beliefs about the meaning of life.

The extent of a cancer in the body. Staging is usually based on the size of the tumor, whether lymph nodes contain cancer, and whether the cancer has spread from the original site to other parts of the body.

A group of people with similar disease who meet to discuss how better to cope with their disease and treatment.

An indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.